Gary L. Curtis co-founded the company that is now eQHealth Solutions, Inc. in 1986. As its president and chief executive officer, he has led the growth of the company
into arguably one of the most effective health care management and quality improvement organizations in the country. Today, the company has multiple contracts
with the Centers for Medicare and Medicaid (CMS) and with state Medicaid agencies in Illinois, Mississippi, and Florida.

Curtis has over 25 years of experience in executive and senior management positions in health care. He has worked directly with the CMS work groups focused on evaluating quality improvement nationwide and developing the wide area network that currently supports the national Medicare quality improvement program and its infrastructure.

Curtis earned a Bachelor of Science degree in economics from Louisiana Tech University and a Master of Social Work degree from Louisiana State University. He
also has completed postgraduate work in quantitative methods, COBOL, multiple programming languages, and structured data system design.

Smith W. Hartley: Can you describe for us the origins of this company, how you began and subsequently grew to where you are today?

Gary Curtis: In 1986 a fellow by the name of Leo Stanley and I were working for the predecessor of this organization. It wasn't optimally organized or governed and the Feds took away their contract. I was building software systems for a number of companies at that point. One I had hoped to use here in Louisiana with the company that failed, but also for Tennessee and Wisconsin. When the Louisiana company
went out of business I had hard decisions to make. I had excellent software to support quality improvement and Medicare and I didn't have a local company. So after talking
back and forth, a number of QIOs (Quality Improvement Organizations) had offered to hire me; they wanted to set up an operation in Louisiana and I thought, you know, if I would be willing to work for them and if I am going to do it I ought to just do it myself.

So we started that way. I talked to Leo, he had been one of our administrative officers in the prior organization, and he was hesitant because the prior organization had worked so poorly, but after going back and forth for a while he agreed at least to help me write the cost proposal and I wrote the technical proposal. We started with about three of us and over about six months of going back and forth with the Feds we
were finally selected as the contractor. So in December of 1986, with a total of less than $10,000 and a lot of hopes and dreams and aspirations, we took the federal contract, hired 105 people in about six months, and it was just as crazy as that sounds.

Because they didn't have an organization for a while we inherited a backlog of work for about six months that took the better part of three years to burn off—the new work and the old work. The Feds didn't give us any advance funding so we were building up equity as we went. It was a “Nightmare on Elm Street.”

After about three years we got back to an even keel. By 1995 we were ready to work on other business. In 1997 we won ourfirst out-of-state contract as the quality control agent for Medicaid in Mississippi. And that doubled the size of the company. We've always been rather slow growth—internal funding. We ran that for about five years before we were ready to grow again. Illinois was attractive to us because they really wanted somebody to work with them that had the data system capacity and infrastructure that we did. We went to Illinois in 2002 and that doubled the size of the company. Two years ago we started working with Florida and they have awarded
us contracts twice now, but we've never actually gotten to do the work because the incumbent has taken the state to court each time. The first time the state kind of wilted and reissued the proposal and we all did the dance again and we won again. This time they've gone to court, but the court ruled in favor of the state this time. We should be picking that contract up probably within the next six weeks. And that's going to be
our largest contract and it's pretty much going to double the size of the company again.

SWH: So you'll be the QIO for the state of Florida?

Gary Curtis: The QIO for Medicaid. There are separate functions, but they are all governed by the Centers for Medicare and Medicaid Services. The state has control over Medicaid. The Feds have control over Medicare. We are the Medicare quality control agent for Louisiana, but not for Medicaid. In every other state we do Medicaid, but not Medicare.

SWH: We know about your Care Transitions project. Can you talk about some of the other quality initiatives you are working on now?

Gary Curtis: If you look at CMS and what Berwick (Donald Berwick, CMS Administrator) is saying, and we've been a partner with Berwick over the years so he's not new to the QIO program, he has taken his Triple Aim program that he had at IHI (Institute for Health Improvement) and is repackaging it for CMS. CMS has a new Center for Innovations. Medicare has always been a bellwether for what is going to
happen in healthcare. It being the largest single payer. With the expansion of Medicaid it's possible for the first time that the federal government will be paying for more than 50 percent of all healthcare in this country because Medicaid is going to grow byabout 30 percent.

So if you want to know what the future of healthcare is you want to look at your largest payer and see what your largest payer is doing. The largest payer has three goals for that innovation center and they are fairly simple, but the middle one is
care coordination. Care transitions and coaching is the beginning step to care coordination, but it is just the first step. In Illinois we are using it to track moms. Because really when you talk about care coordination what you are doing is you are
trying to span settings from the hospital to the physician office to home health because none of those people talk to each other. The gains we make in one setting are very often lost by the time you get to the next one. So we pay twice or three times and sometimes people die because there is no managing of the care across settings. There's also no managing of care across intervals of time. If you have consumed
health services, you know you have to coordinate and organize your own healthcare. There's nobody necessarily reminding you that you need to have your blood tests,
you need to check your blood pressure, you need to get your flu shot. Most likely, unless you are in unusual circumstances, there's not anybody that's going to go home
with you and help you reconcile your meds, to make sure you throw away the old ones and don't get them confused with the new ones. Elderly patients and fragile patients have that problem all of the time. We in America are paying outrageous amounts of money because we are simply not fixing it.

I have a blog and I'm listing about 20 of those things. Those are the reasons we are paying so much for healthcare. They generally all have a resolution, they are well
known, and the interventions to fix them are well known, it's just that we aren't very good at providing leadership across populations or across governments to get a hold of those drivers. Some of them are as simple as the Care Transitions project, but care transitions is the first baby step—it needs to be propped up to where everybody has
care coordination going on. Whether you are in a managed care outfit or whether you are being paid fee for service it just makes sense to do preventive care, patient
safety, and care coordination. And those are the three innovative things that Berwick is asking his Innovation Center to do.

SWH: Do you think the state of Louisiana's Medicaid initiative is the right thing to do? Are they missing something? As somebody who studies policy what do you think the state is doing right or wrong with this move toward care coordination?

Gary Curtis: That's a difficult question because we're a political environment and everybody doesn't always say exactly what they are doing or exactly what they mean. And I don't think all of the cards have been dealt yet. There are people who are looking to managed care and a prepaid health plan as the single answer. That, in my
experience hasn't worked in a lot of states. I'll just recount my personal experience without trying to bias it one way or another. We play dual roles; if there's a fee for service environment we are the pre-authorization agent and we do quality review. If they are a managed care entity we are the external review agent for the state to make sure that the managed care companies are doing their job. When we went into Mississippi there were four managed care Medicaid companies and there were going to be five. Instead it went the other way. It went from four to three and three to two and for the last ten years there have been none.

Managed care companies are usually for-profit entities and they are set up to make money. When you are a for profit entity and you are set up to make money the first principle has to be a return on investment on your equity.

If you are not going to take that pledge and hold true to it then you should stay out of the capital markets and become a non-profit or some other entity. But if you say you are a for-profit then that's the first thing on your shingle. In healthcare, the first thing on your shingle has to be “first do no harm.” So you have competing agendas at the
very top of it and it's hard to reconcile those. I'm not saying that it doesn't ever work because it does. We have examples of it. But my first example was Mississippi where I've been. My second example is Illinois. Illinois is talking again about going down a managed care route, but when I went to Illinois it had a managed care penetration
rate of about 30 to 32 percent. We were the EQO contractor overseeing about six to seven health plans, including most of the big ones. They were trying to take penetration rates from about 30 percent to 60 percent and claimed they were going to do it within three years. Instead it went the other way and went to 25 percent.
Then it went to 18 percent and right now it's 8 percent. So if you are going to pull out a silver bullet and say prepaid, commercial health plans are going to be the answer to the Medicaid population, I am going to have to tell you that we need to talk more about it because that does not fit my experience.

SWH: Could we say that being capitated and being for-profit just fundamentally wouldn't work?

Gary Curtis: No, because I believe there are ways to reconcile “first do no harm” and return on investment. I'm just saying it is hard to do.

SWH: There's just a natural suspicion built in to the model?

Gary Curtis: Not any more so than how many painters do you interview before you hire someone to paint your whole house? And how many times have you had a
painter come out that you were disappointed in? Or bought a car where they didn't expose all the weaknesses? It's buyer beware and healthcare is a very complex situation. You can't apply the free market to it because there's not enough information available to the purchaser and without that information they can't make wise decisions. So you have a very warped market where you really need some
protections built in.

I would say the thing that Louisiana needs to do, that every state needs to do, is to have more than one bullet. Asking pre-paid managed care to be the silver bullet I think is a mistake because you need multiple forms to deliver coordinated managed care. The new Healthcare Act allows for accountable care organizations. They don't really define what those are, but an accountable care coordination entity could be anybody that cobbles together an arrangement of physicians, home health, acute care hospitals, maybe even long term care and goes about the business of taking care of populations of patients over intervals of time and across sites of care. My humble opinion is that every state would be well placed to try every different application of that they could find. New Orleans isn't at all like Lake Charles, which isn't at all like Alexandria, so to find that you would need different infrastructures in those three places wouldn't surprise me. I don't think it would surprise you. So why say one size fits all? Why not let the organizations in those communities form these accountable care organizations in the ways that best fit their community and let them all go to
the dance and well see which one we like better? Successful models over time will be replicated and failures will morph into something more successful or be replaced.
That's the way our market works. The faster we can do that the sooner we would get to a place where, as a population in Louisiana, we have choices about the types of ways we want care delivered.

SWH: What is your opinion on the national health bill and how do you think it will play with Louisiana?

Gary Curtis: That's a dicey situation, but I'm not going to avoid it. You would have to say that the bill is not what anybody really wanted. It's not healthcare reform; for the
most part it's insurance reform. I'm not the first person to say that. It's got a number of things that people really like that I personally like, that probably you all like if you have
kids. Because my kids are now back on my insurance policy and I'm not having to pay $500 a month for both my son and my daughter. I thought I was being a pretty good parent and part of corporate America even though a non-profit part, but I've started for-profits also, so I understand the system and the way it works and I participated
in the insurance policies all my life. Then I find, just because my kids have aged out, but not enough to be on their own, we are all paying big prices. So that's I think a very welcome feature that Middle America, along with me, really supports. The feature about pre-existing conditions–in my conscience I can't say that if you happen to have a history of cancer or breast cancer in your family that because you change jobs you will never have health coverage again. My conscience won't let me do that and I don't think I am very far from the center. So I think there are things about this bill that are very compelling that at least move us in the right direction, although in total, there's a lot of stuff hanging off of it thatmake a lot of people uncomfortable that we need to look
at. But I'm glad to see us taking one step forward rather than nothing, because that's what's been happening up until now.

SWH: Theres always been talk about tying provider compensation to quality care. Is that really feasible and how do we do that?

Gary Curtis: Yes. Let's take readmissions for example. Our project, which was written up in the New York papers and won an award from CMS, out of the thirteen
or so projects we're the poster child for success. It is that way because the hospitals in the Baton Rouge area have made it so. The hospitals in the Baton Rouge area have recognized that CMS, the Feds, are going to come along and bundle payments. In other words if you go into the hospital with pneumonia, right now if you get discharged
and readmitted they get a whole new DRG (Diagnosis Related Group) payment every time you cycle back through. The Feds have said to Baton Rouge General, to the Lake, to all the five hospitals in our area, “We're going to move to a payment where we're going to bundle the payment. We're going to pay you maybe 1.3 or 1.7 of a DRG and then it's your business to keep that person out of your hospital.” Now to a hospital that knew they had very frequent readmissions for a specific diagnosis they're looking at that and saying “I've been getting paid every time and now I'm getting paid 1.3, 1.5, or 1.7 so I'm going to have to take steps here that I haven' taken before.” To do that you have to coordinate care and Care Transitions is the beginning of that.

But Care Transitions and readmissions is an outcome. It is a very specific item we can count. It's not hard to do it, but it is an outcome of care. It's not just per anything. If you can keep your pneumonia patients healthier and keep them out of the hospital then you are going to do well under bundled the way we pay physicians. Right now, in the way that physicians are being reimbursed to use EHRs, you'll get your first incentive payment for just going to get an EHR system and setting it up. There's another step up increase where you'll get another participation because you are actually using it for e-prescribing and things like that. The highest level of participation is called meaningful use. Meaningful use is actually going to be where that physician is showing he's using his EHR information to make sure the care for that patient is coordinated in some fashion. We don't know how that final payment is going to work out. There are a lot of ends to tie up on how that will actually be done. But all of those type things, even if they are just process measures, will prove the physician is counting the number of HbA1c tests you've had, he's actually maintaining a file for you on lipid profiles,
diabetic eye exams, prevention, immunizations, well-person checks. So we will be moving from paying a physician from simply another click because a patient walked through to an outcome. Not totally, but part of his reimbursement will be tied to those outcome steps.

It's a logical thing to do. It's very reasonable. It's possible for us to do it and I'm quite certain that we are going to do it. It's a matter of how soon can we get there? But the problem is really extremely urgent. A lot of people don't agree, but I remember when people were complaining when healthcare costs were about 13% of the GDP. Now it's up around 17% to 19% and it's going to go to 25% percent before we can ever do anything about it because EHR adoption is not going to be a reality in three years and
meaningful use is going to lag probably another three years behind that. Truth be known, we are going to go through the next ten years without the infrastructure that we really need to coordinate care. From this point there is nothing we can do about it. But if we do everything we need to right now, in ten years we can have a handle on coordinating care for patients across settings and across intervals of time. If we don't do it and we don't start now, then the price we will pay in our economy will be catastrophic because we will move from 25% to 35%. All the cost drivers are faced
the wrong way. Physicians are being paid to do more and more procedures and more and more surgeries and the less time spent with the patient means more money in their
pocket. Those are all very focused, very specific incentives that we are applying right now and they are all wrong. We have to reverse the incentives that we have in place that are driving the costs of healthcare in very specific ways and we have to do so with a sense of urgency in my opinion.

SWH: Is there anything out of the box that's not being discussed? What are we missing?

Gary Curtis: I think the thing that isn't talked about is patient safety. Hospitals are very dangerous places and people die in hospitals every day from avoidable conditions.
That's not a subject everybody wants to read. And it's not a topic where you are going to get a group of physicians and some hospital administrators, CFOs, and even
QIOs and very often have a discussion. But Don Berwick is all about that. He is going to take this country and he is going to take CMS and we're going to have more and more discussions about unnecessary deaths coming while we are trying to deliver care. And the message there is a critical one. It's not the fault of the caregivers; the doctors, the nurses, the administrators are all doing what they can. But our systems and infrastructures that those people have to operate in are broken. Just as in the same way as we had Katrina after the disaster in New York with the Twin Towers — nobody could talk on the same radio frequencies. Simple enough to fix. Don't you think after the Twin Towers crashed that in Katrina they would have been able to talk to
each other? But we know that didn't happen and that they couldn't. The Feds couldn't talk to the State and the State couldn't talk to the Feds and the sheriffs were going, “Well we're throwing everybody out.” In other words we had a mess. That's not because of bad intentions. It's because the systems that we set up weren't adequate to do the job. That's what we have in healthcare. We have an inadequate patient safety infrastructure and commitment to keep needless deaths from happening. I think Berwick will lead us through it, but if there's something hidden that's not being
discussed, I think that's probably it.

SWH: Can you tell us about the contract for health information technology you were awarded in Mississippi?

Gary Curtis: We were awarded the contract to be the regional extension center for health information technology in Mississippi. It was a competitive process that we went through with the Feds to get this. They've made the commitment that electronic health records are what they want. They saw the model that they are using with agricultural extension centers as the way to go about it so they set up a process where companies could become regional extension centers for health information technology for different geographies, in most cases a full state. So we bid on that
contract and we were selected. What that means is we now have staff that is working daily in Mississippi with physician offices and small hospitals to help them establish EHR in their practices.

We did get a CMS/ ONC (Office of the National Coordinator for Health Information Technology) recognition for our work there. As far as we can tell, Mississippi, because of our work, is leading the nation. We'e got about 1600 physician practices at last count that have taken at least a step and have committed that they are going to do it. They may be in the beginning stages of it or all the way through up to the end stages, but by and large most everybody is at the beginning. That is huge, but the beginning to that work, although that work is in Mississippi, began over two years
ago in Louisiana. And we have, out of our own nickel because our board is largely physicians and we're a 2000 physician member organization, we've put up to $.25 million a year into providing staff to Louisiana physicians and in some form or fashion have worked with about 700 over the last 24 months. We were shooting competitively for the contract for Louisiana and we didn't get that. The Quality Forum was awarded it. So they've got their own progress report I'm sure, but we are proud that we were able to use that experience and transfer it over to Mississippi. Because physicians having the infrastructure to be able to talk to people is the beginning step. It's hugely important.

SWH: You have a summit in April. Can you tell us a little bit about that? Why do you do that and what should we expect?

Gary Curtis: The “why” question is a very good one. We had started on a smaller scale where every contract cycle, every three years, we were taking major objectives from the federal government to work on prevention of hospital acquired infections, or transitions, or care coordination, or patient safety issues and prevention. We have had some providers that originally wanted blinded results, but after they got together and talked, they said, “Okay take the covers off, we want to see what each other is doing.” So we did and it produced some camaraderie, I think, between the
various providers and they started trading information about how they did this, that, and the other. So it was pretty much their idea to have an awards ceremony for those
of us that are doing best. Let's crow a little bit about these achievements because to be truthful, all of these people work very hard day in and day out and they don't get recognition from the public. Nobody knows that they're doing it. They themselves know they are doing it. So this awards function annually is to sit down and say thank you to all of the providers that are working. They are doing this voluntarily and there's no money attached to these awards, but they can take it back to their communities and tell their communities, “We just got recognized by a federal entity that we are doing the things that we are supposed to be doing in our community.” That's the why of it. It's just a chance to say thank you.

The philosophy is if you are seeing a behavior you want repeated then reward it and you'll get more of it. That has been true and a function throughout the objectives regardless of which one. It has propelled providers to take stronger and stronger positions and going and talking to their chief operating officer or their chief of staff or their CEO saying, “We want to do this, we believe it's good for patients, it's good for the community and we can use these awards and we'll put it in the paper and we'll make this facility look good.” So that's the why and that's how it works. Each year has gotten better so we're very proud of it. The awards are based on key metrics established by the Feds for quality improvement. You are not going to get recognized
unless you have made significant improvements in this particular indicator. When you start looking at the care and looking at the key measures of quality that CMS believes need to be improved upon, those are the ones that they pay us to work with the providers, and those are the metrics that the providers are in turn improving on.

SWH: So personally what's next for you?

Gary Curtis: I read your article with Greenstein (HJBR Jan/Feb 2011) and I have met with him a couple of times. And I asked him the same question that I will pose now. What I'm looking for is the conversation that we need to have. I have been here for 25 years and I know John Matessino of the Louisiana Hospital Association, and I know Mike Reitz over at Blue Cross and I've known them for a long time, and we've had conversations over the years, but the conversations that we've had have resulted
in a system that's not sustainable. It's costing too much money to do it. Even if the results were better than they are and they aren't great. I mean when you take a look at readmissions and say that readmissions are at a level of 20%, that means that your industry has a failure rate of 20%. There is no other industry in America that could exist with a 20% failure rate, yet we put up with it in healthcare all day long and don't think anything about it. The truth of the matter is that's just one example; hospital acquired infections could be considered another, where we're not only destroying families and individuals, but it's costing us a Georgia fortune to do it. I want to find the conversation that we could have, whether it's me and John Matessino, me and you, me and Greenstein, that would lead to a different result than we are looking at right now. Because I want us to have that conversation and I want us to have that conversation now. I think we need to ask each other questions that we haven't asked each other yet. And maybe one of those questions will lead to a new scenario, somebody saying, “What if? If you can do this I can do that and if we put them both together we'd have maybe an answer.” I'll put up with anything besides the status quo or the conversations we've had in the past. I don't want to hear somebody talk about, “Well they're never going to do managed care in my state.” Or “Fee for service is all there is.” Or “It's my bottom-line and nothing else.” I want a different discussion where we can look forward to something moving. I think it's worth probing each other until we find the conversation that produces that. I'm willing to have 25 of them and junk them all one by one until we get to the proper conversation that we need. That's the first thing in the “what now?” category.

The second thing is I'm going to keep hammering on these cost drivers because I know they are fixable. Addressing all of them seems improbable and impossible, so whether it's insurance companies, whether it's big business, entrepreneurs, the state, I'm saying let's just take two or three of them. There are probably 20 of them, but there are two or three that we could work on this year. Because if we did that, in about seven or eight years we could have hit and made progress on nearly everything
on that list. That seems to me preferable than doing what we are doing now, which is kind of marginal working around the edges with very little commitment to a focused
goal in this state and not just this state, in any state I'm working in.

So I think we look for changing the conversation, I think we look for commitment, and I think we look to get some focus, some leadership, and some energy around about
20 items we just can't afford to do any more.